Prescription for Trouble

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Brian can hardly remember a time when he wasn’t medicated. Diagnosed with depression and attention deficit disorder as a 7-year-old in foster care, he was prescribed Paxil, Ritalin and Clonidine. Now a soft-spoken 15-year-old sporting braces and a baggy t-shirt, he’s learning to live without meds for the first time. “I can notice myself more,” he says. “I realize more who I am.”

Five months ago, Brian came to the Graham School in Hastings-on-Hudson, a 100-year-old cluster of colonial brick cottages that serves as a residential treatment center for troubled teens. Referred by his Washington Heights high school for truancy, Brian was considered fragile and antisocial.

But Dr. Martin Irwin, the school’s new child psychiatrist, had another diagnosis: overmedication. On his advice, Brian gradually stopped taking the drugs–first the Clonidine, then the Ritalin, then the Paxil. He still takes Zoloft, but expects to be off it soon. “I just want to be normal,” he says.

Brian is one of many students at the Graham School rediscovering their “normal” selves. The school already had a relatively low rate of medication–38 percent compared with an estimated 60 to 90 percent at similar centers in the area–but it’s dropping further. Concerned about drug efficacy and side effects, the school hired Irwin to reassess its students. In the past few months he’s lowered their medication rate by 25 percent.

Nationally, it’s just the opposite: Psychotropic drugs are a big business that keeps getting bigger. In 2002, they earned their parent companies roughly $12 billion. Although many psychotropics are still not approved for pediatric use by the FDA, usage among U.S. children increased threefold between 1987 and 1999. A more recent study found that prescriptions for antidepressants nearly doubled among patients 18 and younger between 1998 and 2002.

Foster kids are especially likely to be medicated. A University of Minnesota study determined that 35 percent of St. Louis foster children were on psychotropics, compared to 15 percent of the general population. In Florida, close to 30 percent of foster kids over age 13 took psychiatric meds last year.

Some states and cities are starting to respond. An April report by Texas Comptroller Carole Keeton Strayhorn chastised that state’s child welfare agency for exercising “little meaningful oversight over these medications.” In Connecticut, the Department of Children and Families decided to stop giving foster children Effexor or Paxil, citing a recent FDA warning linking the drugs to suicide.

In New York, it’s hard to know just how many of the 21,300 kids overseen by the city’s 38 foster-care agencies are taking psychotropic drugs–or meds in general. In December, the Public Advocate’s office asked the Administration for Children’s Services (ACS), which oversees foster care, for these stats, but the agency still hasn’t produced them. According to ACS, they reside in a database created in 2000 that still isn’t up and running.

After the FDA alert, ACS did encourage the private contract agencies that directly supervise children in care to review their use of antidepressants and consider alternatives. But without centralized information, there’s no way to know whether or not they complied. “This concerns me greatly,” says Public Advocate Betsy Gotbaum. “If they don’t even know how many are on these drugs, how can they effectively oversee their usage?”

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The country’s half-million children in foster care are more likely than others to struggle with mental illness. A startling 84 percent of foster kids have developmental or emotional problems, according to a study in the Archives of Pediatric and Adolescent Medicine.

But they are also more likely to be overdiagnosed, explains Julie Spooner, a clinical psychologist and former director of mental health for a large foster care agency. “The kids are showing normal reactions to a very dehumanizing and disturbing situation,” she says, and they “have a lot of good reasons to be angry, despondent, fearful, restless, confused.” Rather than address those emotions, foster homes and agencies often turn to medication as a quick fix, particularly if they’re understaffed. In Spooner’s agency, for instance, she was the only person assigned to oversee the mental health care of 600 kids.

While there’s no doubt that some children respond well to medication, other options, like talk therapy, sometimes go unexplored. “You have the teacher, the psychiatrist and the foster parent all breathing down your neck,” Spooner says. “Everyone is pushing the easier solution.”

Yet the drugs may not be easy on young bodies. Side effects of psychotropics range from headaches and weight gain to seizures, liver failure and even sudden death. After analyzing FDA records on the 12 medications most commonly used by children in residential care, the Westchester Journal News reported that they were “primary suspects in the deaths of at least 71 children nationwide” between 1997 and 2001.

Meanwhile, their benefits may be marginal. A 2003 study published in the Journal of the American Medical Association found that 69 percent of children who took the antidepressant sertraline–the generic ingredient in Zoloft–showed some improvement. But so did 59 percent of those who took a placebo instead.

Other studies have been criticized for measuring success in increments rather than by a complete cure. If a drug reduces signs of illness by 20 percent, for instance, should it be considered effective? “If you have 50 percent improvement in a runny nose, you’re still sneezing half the day,” says Irwin. “And you can still be miserable.”

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Rosa, a 32-year old Queens mom and recovering addict, didn’t want her sons on drugs of any kind, but she had little choice when her 15-year-old started acting out in foster care. “The foster parents couldn’t deal with him. They kept putting him in hospitals,” she says. Now home, he still takes Adderall and Abilify to control his temper and depression, though Rosa has slowly lowered his dosage. “He tells me he can’t socialize,” she says. “The medication won’t let him. He’s dying to be off it.”

So when her 9-year-old son, who is still in foster care, was recently prescribed Ritalin, Rosa initially refused to sign the consent form. But after his foster mother threatened to kick him out if he didn’t take the drugs, Rosa felt compelled to agree.

She isn’t the only one, says Jessica Marcus, a staff attorney with South Brooklyn Legal Services. Marcus says some parents learn of their children’s medication for the first time at court, when there’s virtually no room for discussion or compromise. “If there’s a professional saying one thing and a parent saying another,” she explains, “they always say that’s the parent not looking out for the child’s interest.”

Alicia is one of many birth parents who have had to fight for a role in their children’s health care. She discovered only by accident that her 6-year-old son’s foster mother had recommended Ritalin and special ed to help him do better in school.

Alicia was baffled: Before he entered foster care, her son had won awards for his schoolwork. “My lawyer was agreeing with ACS, telling me to just go along with it,” she says. But Alicia was also volunteering at the nonprofit Child Welfare Organizing Project, and knew she had a right to intervene. She showed up uninvited to her son’s case conference and convinced the evaluator to scrap the plan.

Alicia notes that it wasn’t a doctor or even a teacher who wanted to medicate her son. She suspects her son’s foster mother just wanted the higher reimbursement that comes with a “special needs” diagnosis. ACS pays $46 per day for regular foster homes, while those who run “therapeutic” homes get $100 per day.

“When you have these different gradations of foster care, something that is not a money-making proposition runs the risk of becoming one,” says Richard Wexler, executive director of the National Coalition for Child Protection Reform. “There is no one standing between the child and the person with the pills.”

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At the graham school, Irwin does just that. Teaming up with the school’s president, Poul Jensen, and vice-president, Jerry Leventhal, he makes sure that medication is used only as a last resort.

The Graham School itself is designed to help kids feel normal. Students do their homework in a converted chapel with chandeliers and polished mahogany desks. They have extracurriculars like tennis and creative writing.

Graham-Windham, the agency that runs the school, also emphasizes “family-centered services” as the best way to help kids. The agency’s parental consent guidelines go well beyond notification, particularly if medication is involved. The prescribing psychiatrist must, for example, detail what other methods have been tried first and why a specific drug has been chosen. If a drug has not been tested specifically for children by the FDA, the doctor must justify its use.

“They’re the parents, for chrissakes,” says Jensen, who has worked in the field for 35 years. “If we want parents to be responsible for these kids, we shouldn’t hold these responsibilities away from them.”

John Courtney, a former executive of Little Flower Children’s Services, agrees. He considers overmedication an “unfortunate side effect” of a child welfare system that relies too heavily on removing children from troubled homes. To advance an alternative, Courtney and David Tobis, another longtime children’s advocate, recently launched a privately funded demonstration project called the Partnership for Family Support and Justice.

The project is based in the Highbridge section of the Bronx, which has the city’s highest number of foster care placements (329 last year alone). By offering preventive services like substance-abuse counseling, legal and housing assistance, Courtney hopes to keep families from ever entering the system. And, ultimately, this could mean fewer kids on psychiatric meds.

“The foster care system, with some minor exceptions, is not a positive experience” for children, he says. “To keep them out of foster care is to keep them healthier.”

Names have been changed.